NICE falls in older people guideline

Falls in older people: assessing risk and prevention

This Guidelines summary includes section 1.1. For a complete list of recommendations, please refer to the full guideline

Terms used in this guideline

Extended care

A care setting such as a nursing home or supported accommodation

Multifactorial assessment or multifactorial falls risk assessment

An assessment with multiple components that aims to identify a person’s risk factors for falling

Multifactorial intervention

An intervention with multiple components that aims to address the risk factors for falling that are identified in a person’s multifactorial assessment

Older people

In section 1.1, older people are people aged 65 years and older

Older people living in the community

Older people living in their own home or in extended care

Risk prediction tool

A tool that aims to calculate a person’s risk of falling, either in terms of ‘at risk/not at risk’, or in terms of ‘low/medium/high risk’, etc

Preventing falls in older people

Case/risk identification

Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline)

Multifactorial falls risk assessment

Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention

Multifactorial assessment may include the following:

identification of falls history

assessment of gait, balance and mobility, and muscle weakness

assessment of osteoporosis risk

assessment of the older person’s perceived functional ability and fear relating to falling

assessment of visual impairment

assessment of cognitive impairment and neurological examination

assessment of urinary incontinence

assessment of home hazards

cardiovascular examination and medication review

Multifactorial interventions

All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention

In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):

strength and balance training

home hazard assessment and intervention

vision assessment and referral

medication review with modification/withdrawal

Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function

Strength and balance training

Strength and balance training is recommended. Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional

Exercise in extended care settings

Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling

Home hazard and safety intervention

Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team

Home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation

Psychotropic medications

Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling

Cardiac pacing

Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls

Encouraging the participation of older people in falls prevention programmes

To promote the participation of older people in falls prevention programmes, the following should be considered:

healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls

information should be relevant and available in languages other than English

falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant

Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants’ different needs and preferences and should promote the social value of such programmes

Education and information giving

All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention

Individuals at risk of falling, and their carers, should be offered information orally and in writing about:

what measures they can take to prevent further falls

how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components

the preventable nature of some falls

the physical and psychological benefits of modifying falls risk

where they can seek further advice and assistance

how to cope if they have a fall, including how to summon help and how to avoid a long lie

Interventions that cannot be recommended

Brisk walking. There is no evidence* that brisk walking reduces the risk of falling. One trial showed that an unsupervised brisk walking programme increased the risk of falling in postmenopausal women with an upper limb fracture in the previous year. However, there may be other health benefits of brisk walking by older people

Interventions that cannot be recommended because of insufficient evidence

We do not recommend implementation of the following interventions at present. This is not because there is strong evidence against them, but because there is insufficient or conflicting evidence supporting them:*

Low intensity exercise combined with incontinence programmes. There is no evidence* that low intensity exercise interventions combined with continence promotion programmes reduce the incidence of falls in older people in extended care settings

Group exercise (untargeted). Exercise in groups should not be discouraged as a means of health promotion, but there is little evidence* that exercise interventions that were not individually prescribed for older people living in the community are effective in falls prevention.

Cognitive/behavioural interventions. There is no evidence* that cognitive/behavioural interventions alone reduce the incidence of falls in older people living in the community who are of unknown risk status. Such interventions included risk assessment with feedback and counselling and individual education discussions. There is no evidence* that complex interventions in which group activities included education, a behaviour modification programme aimed at moderating risk, advice and exercise interventions are effective in falls prevention with older people living in the community

Referral for correction of visual impairment. There is no evidence* that referral for correction of vision as a single intervention for older people living in the community is effective in reducing the number of people falling. However, vision assessment and referral has been a component of successful multifactorial falls prevention programmes

Vitamin D. There is evidence* that vitamin D deficiency and insufficiency are common among older people and that, when present, they impair muscle strength and possibly neuromuscular function, via CNS-mediated pathways. In addition, the use of combined calcium and vitamin D3 supplementation has been found to reduce fracture rates in older people in residential/nursing homes and sheltered accommodation. Although there is emerging evidence* that correction of vitamin D deficiency or insufficiency may reduce the propensity for falling, there is uncertainty about the relative contribution to fracture reduction via this mechanism (as opposed to bone mass) and about the dose and route of administration required. No firm recommendation can therefore currently be made on its use for this indication†

Hip protectors. Reported trials that have used individual patient randomisation have provided no evidence* for the effectiveness of hip protectors to prevent fractures when offered to older people living in extended care settings or in their own homes. Data from cluster randomised trials provide some evidence* that hip protectors are effective in the prevention of hip fractures in older people living in extended care settings who are considered at high risk

*This refers to evidence reviewed in 2004.†The following text has been deleted from the 2004 recommendation: ‘Guidance on the use of vitamin D for fracture prevention will be contained in the forthcoming NICE clinical practice guideline on osteoporosis, which is currently under development.’ As yet there is no NICE guidance on the use of vitamin D for fracture prevention.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.